Transgender Referral

Reason for Referral*

Forename*

As stated on passport

Known As

Surname*

Date Of Birth*

DD

MM

YYYY

Address*

Street Address City County Eircode

Home Phone*

Mobile Phone*

Email Address*

Enter Email Confirm Email

PPSN*

First Language*

Nationality*

Occupation*

Do you have health insurance?*

Please note that if you are a VHI member, you may be entitled to benefits for fertility treatment, which are given to you directly by the clinic.

Select your health insurance provider.*

Enter your health insurance provider.*

Policy Number*

Have you previously attended Merrion Fertility Clinic for a doctor consultation?*

GP Name and Address*

Weight in Kilograms*

Please make sure your weight is entered in Kilograms not Pounds or Stone. You can use this website to convert your weight.

Height in Centimeters*

Please make sure your height is entered in Centimeters not Millimeters, Feet or Inches. You can use this website to convert your height.

BMI is calculated at (kg/m2)*

Have you ever had any medical problems / surgery? If yes, please provide details below.*

Summary of your medical problems/surgery details.*

Include childhood problems and medical conditions e.g. asthma infection, gynaecological problems or testicular injuries etc.

Do you have a partner or spouse?*

Partner's Forename*

As stated on passport

Partner's Surname*

Partner's Date Of Birth*

DD

MM

YYYY

This field is hidden when viewing the form

Partners Age input upon Application

Thank you for your interest in Merrion Fertility Clinic. We're sorry but you do not meet the criteria for an appointment at our clinic.

Understand Why

Partner's Contact Number*

Partner's Email*

Partner's First Language*

Partner's Nationality*

Partner's Occupation*

Does your partner have health insurance?*

Please note that if you are a VHI member, you may be entitled to benefits for fertility treatment, which are given to you directly by the clinic.

Select your partner's health insurance provider.*

Partner's health insurance provider*

Partner's Policy Number*

Partner's GP Name and Address

Weight in Kilograms (Partner)*

Please make sure your weight is entered in Kilograms not Pounds or Stone. You can use this website to convert your weight.

Height in Centimeters (Partner)*

Please make sure your height is entered in Centimeters not Millimeters, Feet or Inches. You can use this website to convert your height.

BMI is calculated at (kg/m2) (Partner)*

Are you trying to conceive?*

When did you start trying to conceive?*

Next of Kin*

Relation to Patient*

Next of Kin Contact Details*

Do you require special needs assistance?*

If yes, please provide more detail.

Do you require an Interpreter?*

If yes, please provide more detail.

How did you hear about Merrion Fertility Clinic?*

Would you prefer an In-Person or Online Initial Consultation at Merrion Fertility Clinic?*

Please note for all consultations, where applicable both partner's must be in attendance for the consultation e.g. In-Person Consultation - both partner's attend the clinic.

Other website*

Other*

Confirmation*

I confirm that I have read and understand the statement below.

When you submit this form, your information will be reviewed and an appointment will be made for you. Your appointment details and information can be accessed by logging in to our online patient portal (you will receive a link to register). Should you have any queries or if the appointment date does not suit, please contact us.

Consent*

I agree to the Privacy Policy.

Untitled

Online Referral (Transgender)